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The PSNet Collection: All Content
The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
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Displaying 1 - 20 of 30 Results
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Patient Safety Primer
November 18, 2021
Debriefing is an important strategy for learning about and making improvements in individual, team, and system performance. It is one of the central learning tools in simulation training and is also recommended after significant clinical events.
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Patient Safety Primer
October 27, 2021
Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.
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Perspective on Safety
October 6, 2021
This piece discusses an expanded view of maternal and infant safety that includes the concept of whole-person care, which addresses the structural and social determinants of maternal health.
This piece discusses an expanded view of maternal and infant safety that includes the concept of whole-person care, which addresses the structural and social determinants of maternal health.
Alison Stuebe, MD, MSc, is a professor and Division Director for Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology at the University of North Carolina (UNC) at Chapel Hill and the co-director of the Collaborative for Maternal and Infant Health. Kristin Tully, PhD, is a research assistant professor in the Department of Obstetrics and Gynecology at UNC Chapel Hill and a member of the Collaborative for Maternal and Infant Health. We spoke with them about their work in maternal and infant care and what they are discovering about equitable care and its impact on patient safety.
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September 13, 2021
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Patient Safety Primer
April 21, 2021
Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.
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Patient Safety Primer
September 7, 2019
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
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Patient Safety Primer
September 7, 2019
Clear and high-quality communication between all staff involved in caring for a patient is essential in order to achieve situational awareness. Breakdowns in communication are closely tied to preventable adverse events in hospitalized and ambulatory patients.
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Perspective on Safety
May 1, 2019
This piece explores the key role of emergency medical services in providing care to patients at their moment of greatest need, safety hazards in this field, and opportunities for improvement.
This piece explores the key role of emergency medical services in providing care to patients at their moment of greatest need, safety hazards in this field, and opportunities for improvement.
Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University of North Carolina. She also serves as the Program Director for the Emergency Medical Services (EMS) Fellowship and was past-president of the National Association of EMS Physicians. We spoke with her about her experience working in emergency medical systems and safety concerns particular to this field.
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Perspective on Safety
April 1, 2018
This piece explores the risks patients face after hospital discharge and strategies to address them, such as patient education, Project RED, and the Care Transitions Intervention.
This piece explores the risks patients face after hospital discharge and strategies to address them, such as patient education, Project RED, and the Care Transitions Intervention.
Dr. Krumholz is Professor of Medicine at the University of Yale School of Medicine and Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. We spoke with him about readmissions and post-hospital syndrome, a term he coined in an article in the New England Journal of Medicine to describe the risk of adverse health events in recently hospitalized patients.
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Perspective on Safety
March 1, 2018
This piece explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.
This piece explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.
Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research at University of Pennsylvania. She is generally considered the nation's foremost expert on health policy as it relates to the nursing workforce. We spoke with her about how nurse staffing and the work environment can affect patient safety and outcomes.
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Perspective on Safety
January 1, 2018
Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
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Perspective on Safety
January 1, 2017
Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.
Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.
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Perspective on Safety
February 1, 2013
This piece highlights the advantages to and limitations of engaging patients in patient safety.
This piece highlights the advantages to and limitations of engaging patients in patient safety.
Beverley Johnson is President and Chief Executive Officer of the Institute for Patient- and Family-Centered Care.
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Perspective on Safety
August 1, 2012
This piece, written by a national leader in safe use of medications in elderly patients, discusses strategies for improving the quality and safety of medication use in the nursing home setting.
This piece, written by a national leader in safe use of medications in elderly patients, discusses strategies for improving the quality and safety of medication use in the nursing home setting.
An expert on patient safety in nursing homes, Dr. Castle is a Professor at the University of Pittsburgh in the Department of Health Policy and Management.
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Perspective on Safety
May 1, 2011
This piece discusses efforts to ameliorate the impact of errors on providers, including an innovative program to counsel second victims.
This piece discusses efforts to ameliorate the impact of errors on providers, including an innovative program to counsel second victims.
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Perspective on Safety
March 1, 2011
This piece discusses how medical centers can improve handover quality and patient safety.
This piece discusses how medical centers can improve handover quality and patient safety.
An Associate Professor at the University of Chicago, her research focuses on resident duty hours, handoffs, and professionalism.
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Perspective on Safety
December 1, 2010
In 1990, a Harvard-based research team reported the incidence of medical errors in the state of New York, based on the hospital discharge analysis of 30,121 cases.
In 1990, a Harvard-based research team reported the incidence of medical errors in the state of New York, based on the hospital discharge analysis of 30,121 cases.
Geri Amori, PhD, is Vice President for the Education Center at The Risk Management and Patient Safety Institute, and a popular writer and speaker.
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Perspective on Safety
October 1, 2010
The use of checklists is a primitive yet remarkably effective strategy for ensuring accuracy in complex tasks. Checklists have long been used in fields such as aviation and space exploration but have only recently made headway in medicine. The reluctance of medical professionals to adopt checklists is often framed as pushback against "more paperwork" and "cookbook medicine," or due to disbelief in their effectiveness. However, a rich literature has helped establish many best practices in checklist design, and health care now stands to benefit.
The use of checklists is a primitive yet remarkably effective strategy for ensuring accuracy in complex tasks. Checklists have long been used in fields such as aviation and space exploration but have only recently made headway in medicine. The reluctance of medical professionals to adopt checklists is often framed as pushback against "more paperwork" and "cookbook medicine," or due to disbelief in their effectiveness. However, a rich literature has helped establish many best practices in checklist design, and health care now stands to benefit.
Peter J. Pronovost, MD, PhD, is a Professor of Anesthesia, Critical Care, and Health Policy at Johns Hopkins University and Director of the Johns Hopkins Quality and Safety Research Group. He may be best known for having led the Michigan Keystone project, which used checklists and other interventions to markedly reduce catheter-associated bloodstream infections in ICUs throughout the state. For this work and more, he received a MacArthur Foundation Fellowship, and Time Magazine named him as one of the 100 most influential people in the world. We asked him to speak with us about checklists and other thoughts about the science of improving patient safety.
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Perspective on Safety
February 1, 2010
Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say?
Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say?
Thomas J. Nasca, MD, is the executive director and chief executive officer of the Accreditation Council for Graduate Medical Education (ACGME). Prior to joining the ACGME in 2007, Dr. Nasca, a nephrologist, was dean of Jefferson Medical College and Senior Vice President for Academic Affairs of Thomas Jefferson University. We asked him to speak with us about the role of the ACGME in patient safety.
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Perspective on Safety
August 1, 2009
Frontline health care providers are challenged by poorly performing work systems. Required equipment is broken, patient medications are in the wrong dose, key information fails to get communicated, and essential supplies are out of stock.(
Frontline health care providers are challenged by poorly performing work systems. Required equipment is broken, patient medications are in the wrong dose, key information fails to get communicated, and essential supplies are out of stock.(
